Available via license: CC BY-NC 4.0
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CEP Clin Exp Pediatr Vol. 65, No. 2, 73–80, 2022
https://doi.org/10.3345/cep.2021.00143
Review article
A mercury sphygmomanometer (MS) has been the gold
standard for pediatric blood pressure (BP) measurements, and
diagnosing hypertension is critical. However, because of environ-
mental issues, other alternatives are needed. Noninvasive BP
measurement devices are largely divided into auscultatory and
oscillometric types. The aneroid sphygmomanometer, the cur
-
rently used auscultatory method, is inferior to MS in terms of
limita tions such as validation and regular calibration and diffi cult
to apply to infants, in whom Korotkoff sounds are not audible.
The oscillometric method uses an automatic device that elimi
-
nates errors caused by human observers and has the advantage
of being easy to use; however, owing to its measurement
accuracy issues, the development of an inter
national validation
protocol for children is important. The hybrid method, which
combines the auscultatory and electronic methods, solves some
of these problems by eliminating the observer bias of terminal
digit preference while maintaining measurement accuracy;
however, the auscultatory method remains limited. As the age-
related characteristics of the pediatric group are heterogeneous,
it is necessary to reconsider the appropriate BP measurement
method suitable for this indication. In addition, the mobile
application-based BP measurement market is growing rapidly
with the development of smartphone applications. Although
more research is still needed on their accuracy, many experts
expect that mobile application-based BP measurement will
effectively reduce medical costs due to increased ease of access
and early BP management.
Key words: Blood pressure, Child, Mercury, Oscillometry,
Auscultatory
Key message
· Hypertension is defined as a blood pressure (BP) >90th
(elevated) or 95th (hypertension) percentile in children by
height, age, and sex and >95th percentile in neonates by age,
birth weight, and sex.
· Although the oscillometric method can be used for screenings,
the auscultatory method remains the gold standard. The
hybrid method employs the auscultatory and electronic
methods and can reduce bias.
· BP measurement mobile device applications have a potential
for development.
Introduction
Blood pressure (BP) measurement is a common and imperative
component of physical examinations in children and adults.
Although the prevalence of hypertension in children is lower
than that in adults, its early detection is crucial for preventing
later complications. Before recognizing the BP as normal or
high, we must ensure its accurate measurement. BP in children
can be affected by several factors such as measurement technique,
emotional state, and activity level. The accommodation effect
and measurement device type are 2 critical factors for BP mea
-
surement accuracy in children. The accommodation effect
refers to the fact that BP usually decreases as measurements are
repeated. Therefore, multiple BP measurements are recommend
-
ed before the diagnosis of elevated BP.1) There are several methods
for measuring BP, including the mercury sphygmo
mano meter
(MS). First introduced more than 110 years ago, the MS has
been the gold standard method for obtaining BP and diagnosing
hypertension in children. However, because of environmental
issues related to mercury toxicity, the MS will no longer be used.
This review article describes several BP measurement methods
and speculates on what may replace MS in children.
Corresponding author: Seong Heon Kim, MD. Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, 101
Daehak-ro, Jongno-Gu, Seoul 03080, Korea
Email: pedksh@gmail.com, https://orcid.org/0000-0001-8003-3010
The corresponding author previously worked in Pusan National University Children's Hospital but is currently working in Seoul National University Children's Hospital.
Received: 4 February, 2021, Revised: 14 August, 2021, Accepted: 19 August, 2021
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-
nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright © 2022 by The Korean Pediatric Society
Blood pressure measurements and hypertension in infants,
children, and adolescents: from the postmercury to mobile
devices
Seon Hee Lim, MD1, Seong Heon Kim, MD2
1Department of Pediatrics, Uijeongbu Eulji Medical Center, Uijeongbu, Korea; 2Department of Pediatrics, Seoul National University Children's Hospital, Seoul National
University College of Medicine, Seoul, Korea
Clinical and Experimental Pediatrics [Epub ahead of print]
Lim SH and Kim SH. The alternatives of pediatric BP measurement in nonmercury era
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74
usually higher than auscultatory BP measurements.2) Consider
-
ing these 2 guidelines, elevated BP is diagnosed using an aus
-
cultatory device in pediatric patients.
2. Definition of neonatal hypertension
The measurement of BP in newborns is important but diffi
-
cult. Newborns, especially preterm infants, undergo rapid
physiological changes before and after birth, but possible
rapid changes in blood flow and BP make it difficult to classify
measured BP. Neonatal hypertension is identified when the
systolic BP measured 3 times is higher than the 95th percentile
in the BP classification by gestational age, birth weight, and
sex.6,7) The evaluation of hypotension in newborns is also
important. Hypotension is identified when the systolic BP is
less than the 5th–10th percentiles by gestational and postnatal
age.7) In extremely low birth weight infants, information on a
normal BP is insufficient; therefore, mean arterial BP, which is
lower than the newborn’s gestational age in weeks, is clinically
used as a treatment criterion.7) In neonates, especially in cases
of arterial catheterization through the umbilical artery, intra-
arterial BP through the catheter is the gold standard method for
neonatal BP measurements.6,8) Neonatal movement, feeding,
catheter position, and appropriate catheter size for the vessel
Definition of hypertension in children
1. Definition of pediatric hypertension
After the American Heart Association (AHA) and American
College of Cardiology proposed that a BP higher than 115/
75 mmHg increases one’s risk of cardiovascular disease and
mortality, it lowered the standard adult cutoff value of hyper
-
tension. In 2016, the European Society of Hypertension (ESH)
guidelines suggested that a normal BP was less than the 90th
percentile for persons aged 1–16 years and less than 130/85
mmHg for persons aged over 16 years.2) In 2017, the American
Academy of Pediatrics (AAP) guidelines changed the standard of
an elevated pediatric BP to that above the 90th–95th percentiles
by height, sex, and age for persons aged 1–13 years and above
120/80 mmHg for persons over 13 years of age in line with the
decrease in adult standard3-6) (Table 1). If BP measured by the
oscillometric device is above the 90th percentile, auscultatory
BP should be measured repeatedly, and if the average of BP is
also higher than the 90th percentile, it is considered elevated;
in contrast, if it is less than the 90th percentile, it is considered
normal and monitored with an oscillometric device.5) The
ESH recommended the confirmation of hypertension using an
auscultatory device since oscillometric BP measurements are
BP measurement in children: auscultatory and oscillometric device
Aneroid sphygmomanometer Hybrid auscultatory device Oscillometric electronic device
Next generation:
mobile application-based
BP measurement
The gold standard of HTN diagnosis
When auscultation is difficult
(neonate or small children)
Apply to 24hr ABPM
Pros
Direct estimation of BP
Inexpensive
No need for calibration
Elimination of bias
(terminal digit preference)
Easy to use
Fewer observer errors
Good for screening
Cons
Skilled observer needed
Regular calibration needed Same as aneroid Standard validation protocol needed
Manufacturer variation
Graphical abstract. BP, blood pressure; HTN, hypertension; ABPM, ambulatory BP monitoring.
Table 1. Definition of hypertension
17,41,42)
Neonates
Definition of HTN ≥95th percentile for gestational age, birthweight, and sex on 3 separate occasions
Significant HTN 95th–99th percentile for age and sex
Severe HTN ≥99th percentile for age and sex
Children
1–13 Years ≥13 Years
Normal BP <90th percentile <120/<80 mmHg
Elevated BP ≥90th percentile to <95th percentile or 120/80 mmHg to <95th percentile (whatever is lower) 120/<80 to 129/<80 mmHg
Stage 1 HTN ≥95th percentile to <95th percentile + 12 mmHg, or 130/80 to 139/89 mmHg (whatever is lower) 130/80 to 139/89 mmHg
Stage 2 HTN ≥95th percentile + 12 mmHg or ≥140/90 mmHg (whatever is lower) ≥140/90 mmHg
BP, blood pressure; HTN, hypertension.
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75
may change intra-arterial BP; therefore, caution is required
in judgment.9) However, if catheter insertion is not indicated,
methods other than intra-arterial BP monitoring, which is highly
invasive, should be considered. Oscillometric devices are used in
newborns, as their Korotkoff sounds are almost inaudible using
auscultatory devices.
What are the auscultatory methods?
Blood circulation in the body is caused by the continuous
pumping action of the heart, which creates a pulsating flow when
it drains blood from the left ventricle to the aorta. The systolic
BP (SBP) is defined as the maximum pressure exerted against the
inner walls of the blood vessels when the left ventricle contracts,
while the diastolic BP (DBP) is defined as the force exerted during
relaxation and dilation of the heart.10) A noninvasive auscultatory
method that easily measures arterial BP using a stethoscope and
the bladder of the BP cuff was developed about 110 years ago
by Nikolai Korotkoff.11) Despite efforts to establish a superior
BP measurement method, the auscultation method by Korotkoff
remains the gold standard. Initially, Korotkoff described 4 sound
phases, to which a fifth phase was added later. The pressure at the
first audible sound during the slow loosening of the inflated cuff
(Korotkoff phase I) was recorded as the SBP, while the pressure
at the moment all sounds (Korotkoff phase V) disappear was
recorded as the DBP. A sphygmomanometer and stethoscope are
required to measure arterial BP using Korotkoff’s auscultatory
method.
A sphygmomanometer is a device attached to an inflatable
bladder (cuff) through a rubber tube and consists of a pressure
gauge or mercury column. The auscultation method using an
MS is the gold standard for recording BP. An MS usually does
not require calibration since the density of mercury cannot be
changed, although periodic maintenance is necessary, such as
filter cleaning.12) Due to environmental and personal health
concerns, international efforts have been made to discard
healthcare sources of mercury in the thermometer and sphygmo
-
manometer and replace them with less toxic alternatives.13,14)
Therefore, the clinical standard of auscultatory methods using
mercury columns has given way to oscillometric devices in
recent adult guidelines.15) However, the MS is considered the
standard device for BP measurement in epidemiological surveys
in adults.16) Moreover, in children, it should be noted that the BP
table for the diagnosis of hypertension was made based on values
using an MS.2,17) There is a need for a method that can replace
MS for measuring BP and diagnosing hypertension in children
and adolescents.
1. Aneroid sphygmomanometer
The aneroid sphygmomanometer is a device in which a
mercury pressure gauge is replaced by a set of bellows and
mecha nical springs.18) However, unlike with MS, the aneroid
sphygmomano meter may involve intermanufacturer differences
in accuracy. Studies of its accuracy in clinical settings have
reported varied results, with the frequency of defective devices
varying from zero to more than 35%.18-20) Another major concern
of aneroid sphygmomanometers is the issue of maintenance
and recalibration, which is not needed for the MS. This device
should be regularly (no more than every 6 months) calibrated for
accuracy using dynamic calibration methods as recommended
in validation protocols.21) A simple way to check the calibration
is to verify that the needle is not pointed to 0 mmHg when the
manometer valve is open.12)
1) Advantages
Auscultatory BP measurement directly measures SBP and
DBP through Korotkoff sounds. It is inexpensive and portable
and does not require electricity, making it the gold standard for
pediatric BP measurement and hypertension diagnosis.3-5)
2) Disadvantages
A common disadvantage of the auscultatory method is the
requirement for an experienced examiner to perform the
measurement. Also, mismeasurements due to examiner error
are possible (Korotkoff sounds are difficult to hear, especially
in young children), resulting in the underestimation of SBP or
confusion of Korotkoff phases IV and V.10) As mentioned above,
auscultating the Korotkoff sounds using small vessels of neonates
is difficult, and pressing the stethoscope down on the arm causes
bias since it increases the diastolic pressure. Therefore, use of the
auscultatory method for newborns is not recommended.9)
2. Hybrid sphygmomanometer
Hybrid sphygmomanometers are another type of aneroid
sphygmomanometer that combines electronic and auscultatory
devices. The measurement of BP with a stethoscope is the same
as that of an MS.18,22) The Accoson Greenlight 300, a hybrid
sphygmomanometer, is the first nonautomated and mercury-
free device that meets the international protocol for adults
with guaranteed accuracy. It can fulfill the desire expressed by
a consensus of experts representing the AHA.23,24) Thereafter,
it became known that devices such as the A&D UM101
hybrid device (A&D Co., Ltd., Toshima Ku, Tokyo, Japan), Pic
Indolor Professional hybrid device (Pic Indolor Professional,
Artsana Co., Milan, Italy), and Nissei DM3000 (Nissei Japan
Precision Instruments, Gunma, Japan) could replace the MS in
the validation study of the ESH international protocol 2010.25)
Hybrid devices also have advantages of improving auscultatory
BP measurements as they have a self-zeroing feature; thus, they
can obviate the surveillance protocol that is required to ensure
aneroid BP measurement device accuracy.24)
1) Advantages
The auscultatory method remains the gold standard for
diagnosing hypertension in pediatric patients. Hybrid devices
have an electronic pressure gauge but do not use a specific manu
-
facturer’s algorithm. The cuff pressure is accurately displayed
Lim SH and Kim SH. The alternatives of pediatric BP measurement in nonmercury era
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76
on a digital light-emitting diode to eliminate terminal digit
preference by the measurer.18)
What are the oscillometric devices?
Oscillometric devices have the advantage of eliminating
human observer errors since they all provide a digital readout of
the BP. Unlike the auscultatory method, oscillometry calculates a
person’s SBP and DBP, and each manufacturer of oscillometric
devices uses its own algorithm for the calculation by examining
the reflected oscillating pulse wave that is generated inside the
deflating bladder.10,12) A typical oscillometric device automati
-
cally inflates the cuff and then gradually deflates it to a pressure
below the diastolic pressure. The oscillations begin above the
systolic pressure and continue below the diastolic pressure so the
SBP and DBP can only be estimated indirectly according to some
empirically derived algorithms. Even a child’s small movements
can affect oscillometric pulses, which are essential to determining
an accurate BP; therefore, it is challenging to measure BP in
children who cry, shiver, or move.
The empirical nature of oscillometry requires validation of
each model’s accuracy.26) Although many devices are marketed
by different manufacturers, less than 15% pass validation studies.
This issue is crucial in children, in whom few devices have been
successfully validated using an established protocol.27) Recent
studies described models that have been validated in children,
and we can read a device’s user manual to see whether validation
was performed and what protocol was used.27) Oscillometric
devices are convenient because their measurements are fully
automated, they do not require training, and they have good
interrater reliability. However, their accuracy in children remains
uncertain. Each method mentioned above has advantages and
disadvantages (Table 2).
1. Ambulatory BP monitoring
Ambulatory BP monitoring (ABPM) is a method of repeatedly
measuring BP several times over a certain period (usually 24
hours). ABPM uses the oscillometric and auscultatory methods,
but the former is mainly used because of the disadvantages of the
latter, specifically measurement difficulties and the absence of a
normal reference value. The BP cuff is wrapped around the arm,
a small monitor is connected, and the BP is repeatedly measured
every 15–30 minutes while the device is connected to the body.
The measured BP is stored, and when the test is completed, the
data are downloaded to the computer and analyzed.28,29) The
interpretation of the results follows AHA guidelines. Through
this method, the mean value and day/nighttime ambulatory BP
information of BP are provided to enable the identification of
hidden variations of hypertension. ABPM can confirm an office
Table 2. The advantages and disadvantages of each method
10,18,28-30,43)
Aneroid auscultation Hybrid auscultation Oscillometry
Method of
BP estimation
Detection of Korotkoff sounds through a
stethoscope for auscultation
Combination of features of electronic and
auscultatory devices (auscultat
ing Koro
-
tkoff sounds and indicating cuff pressure
on digital light-emitting diode readout)
Detection of arterial flow (oscillometry) in
which pulses sensed through the cuff are
filtered, amplified, processed, and applied
to an algorithm to estimate systolic and
diastolic BP
Advantages - Direct estimation of SBP/DBP (more
accurate)
- Inexpensive and portable
- Dose not require electricity
- Same as aneroid
- No need for regular recalibration
- Cuff pressure exactly indicated as a digital
light-emitting diode value, resulting in
elimination of the terminal digit prefer
-
ence
- Portable
- Easy to use; saves time and clinical
resources (less expertise and training
required when used in the absence of a
healthcare provider)
- Fewer observer errors; minimal obser
ver
bias or terminal digit preference
- Good for screening, home use
Disadvantages - Risk of noise interference
- Expertise and retraining required to avoid
observer error; (1) requires manual dex
-
terity to ensure a proper cuff deflation rate,
(2) requires ex
cellent hearing and vision
- Risk of observer bias and terminal digit
preference
- Requires regular calibration (at least every 6
months); device can lose calibration
(become inaccurate) when jostled or
bumped, leading to false readings
- Same as aneroid except for bias of ter
-
minal digit preference
- Very few devices available to date
- Requires access to a continuous power
source (electricity or battery)
- Requires validation by a standard protocol
(some are only for adults); some are
inaccurate; manufacturer variation due to
proprietary algorithm for estimation
- Device cost and longevity
- Must be replaced periodically because of
mechanical failure
- Many are not suitable for patients with
atrial fibrillation, decreased arterial com
-
pliance, motion, or crying
Pediatric area - To date, it is the gold standard for hypertension diagnosis
- In infant/young children, SBP may be underestimated due to poor hearing of Korotkoff
sounds, or DBP may be incorrectly measured by confusion of Korotkoff phases IV and V
- It can be applied when auscultation is
difficult, such as in small children or
newborns
- When applied to 24-hour ABPM, it can
detect masked hypertension and help
diagnose hypertension in patients with a
high auscultatory BP
BP, blood pressure; DBP, diastolic BP; SBP, systolic BP; AMBP, ambulatory blood pressure monitoring.
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elevated BP since it excludes white-coat hypertension or detects
masked hypertension; moreover, it can better predict future BP
after adulthood and is known to be particularly related to end-
organ changes (ex, left ventricular hypertrophy). Therefore, the
AAP guidelines recommend that children and adolescents with a
high office BP undergo ABPM to confirm hypertension and that
clinicians consider performing annual screenings of high-risk
groups such as those with chronic kidney disease and diabetes.5)
This method is technically difficult in children under 5 years of
age.28)
1) Advantages
As this method does not require measurer expertise, it is
easy to access, removes measurer bias, and eliminates white-
coat hypertension because it can be measured by the patient
alone.18,28,30) Continuous BP measurements can be performed
in a short amount of time. The advantage of electronic monitors
is that they are less likely to cause inaccuracies in mechanical
devices, such as mercury or aneroid devices, since they eliminate
terminal digit preference by the measurer. It is good to use as a
method of hypertension screening tests, such as school checkups.
As mentioned above, it is difficult to hear the Korotkoff sounds
using auscultation in neonates or infants, so the oscillometric
method is applied instead.
2) Disadvantages
This is an indirect BP measurement, as BP is measured by
calculating SBP and DBP from the mean arterial BP measured
using each manufacturer’s algorithm. In addition, the algorithm
varies for among companies, so BP may vary accordingly. In
addition, the measurement value may vary among patients
with different underlying diseases, so it is difficult to trust the
measurement value in cases of arrhythmia, and the accuracy of
the result is theoretically poor for elderly, diabetic, and dialysis
patients with poor arterial compliance.28,29)
Comparisons of mercury and other devices
1. Mercury vs. aneroid sphygmomanometer
Only a few studies have compared the accuracy of mercury
versus aneroid sphygmomanometers in children. A large study
published in 2012 demonstrated that mean mercury and aneroid
systolic and diastolic BP were highly correlated. There was no
significant difference in mean SBP, but a lower mean DBP (by
-1.53±5.06 mmHg) was seen in the aneroid device group.
Although a small discrepancy in DBP measurements exists
between aneroid and mercury devices, this variation is unlikely
to be clinically significant, suggesting that either device could be
used in research or clinical settings.31) Another comparison study
using data of 727 individuals (127 of whom were 8–17 years
old) in the U.S. National Health and Nutrition Examination
Surveys showed that the mean readings were not significantly
different between the 2 methods except for SBP in patients
aged 8–17 years (mean difference, 1.10 mmHg).16) In a recent
systematic review article, only 3 studies compared aneroid and
MS.32) In an additional study on adults in 2015, the BP measured
using mercury, aneroid, and digital devices in 108 subjects were
analyzed by paired t test. The average SBP was 124.57 mmHg for
digital devices, 124.31 mmHg for aneroid, and 125.01 mmHg
for mercury, and there was no significant difference in mercury-
aneroid, mercury-digital, and aneroid-digital measurements,
so it was argued that a digital device or an aneroid device could
replace a mercury device.33)
2. Mercury vs. oscillometric device
A recent meta-analysis (random-effects model) analyzed 34
studies comparing oscillometric devices with MS performed
before July 2015.32) The oscillometric devices showed higher
SBP than MS, with a pooled effect of about 2.53 mmHg (95%
confidence interval [Cl], 0.57–4.5; P<0.05). In the studies that
passed validation, the pooled effect decreased to 1.75 mmHg
(95% Cl, 0.61–2.81; n=12). There was no significant difference
in DBP, which is defined as Korotkoff phase V. However, in some
studies that defined DBP as Korotkoff phase IV by auscultation,
oscillometric devices underestimated DBP. The limitation of
this study is the large interstudy heterogeneity. Studies in clinical
situations other than school-based studies found no differences,
although these studies comprised only a small proportion
of all studies.32) A study comparing a mercury device and an
oscillometric device in 77 obese pediatric patients aged 5–17
years was published in 2017. The mercury device showed
significantly lower SBP and DBP values than the oscillometric
device (Omron HEM 725 CIC, OMRON Healthcare, Kyoto,
Japan) at 104.0±9.6 mmHg/61.1±9.5 mmHg for the mercury
device and 107.8±14.5 mmHg/71.4±15.8 mmHg for the
electronic device.34) Another meta-analysis published in 2019
compared measurement methods among patients older than
15 years of age in 24 papers and found that the oscillometric
device had a lower SBP (mean difference, -1.75 mmHg;
95% CI, -3.05 to -0.45 mmHg; I2=91.0%) and DBP (mean
difference, -1.20 mmHg; 95% CI, -2.16 to -0.24 mmHg;
I2=95.0%),35) showing contradictory results with those of the
previous study. A sub-group analysis revealed differences among
manufacturing companies. The BpTRU monitor (VSM MedTec
Ltd., Vancouver, Canada) showed lower results than mercury
devices (SBP, -4.08 mmHg; DBP, -2.5 mmHg), and there was
no significant difference with the OMRON BP mercury device
(OMRON Healthcare), but the results differed among devices.
However, this study has a limitation in that its heterogeneity was
exceedingly high. It is important to establish a validation protocol
for the algorithm because the studies published to date reported
conflicting conclusions and differences among manufacturers.
In addition, more research is needed to determine whether
oscillometric devices can replace mercury devices in pediatric
patients.
Lim SH and Kim SH. The alternatives of pediatric BP measurement in nonmercury era
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Next-generation BP measurements in the
mobile era
Recently, as the tools for BP measurement have diversified
and the mobile market has evolved, a method using a mobile
application for BP measurement has emerged. Instead of
wrapping the bladder cuff around the arm and pumping air into
it, a user simply places a finger on the smartphone to measure BP
and checks the results through the mobile application. When the
patient puts a finger on the smartphone camera sensor, the sensor
emits a 940-nm light-emitting diode, the light of which reaches
the photodetector after passing through the finger.30) This
photoplethysmography (PPG) signal detects changes in blood
flow corresponding to the patient’s natural pulsation, and SBP
and DBP can be measured according to the algorithm of each
application. In 2020, traditional BP using an arterial catheter
and BP using a smartphone were simultaneously measured and
analyzed in 50 adults to determine the accuracy of “BP measured
by applying the PPG signal obtained from the smartphone to
the dedicated app (OptiBP)”.36) The difference between the 2
values showed only the difference of SBP -0.7±7.7 mmHg, DBP
-0.4±4.5 mmHg, and mean BP -0.6±5.2 mmHg, confirming
the accuracy of mobile application-based BP. Another study
compared the BP of senior nursing students (aged over 18 years)
using a traditional automated BP cuff versus that using PPG
signals in Apple iOS health applications. The article reported that
DBP was significantly overestimated by the mobile application
at SBP 122.94 mmHg/DBP 76.62 mmHg in the traditional
method and SBP 125.72 mmHg/DBP 81.86 mmHg in the
mobile method.37) No studies have examined smartphone-based
PPG using BP measurements in children. However, in a study
comparing BP with standard ABPM using pulse transit time, a
cuffless BP measurement method, the mean SBP and DBP of 30
patients aged 10–18 years with primary hypertension or a high
normal BP were evaluated. As a result, the cuffless device showed
a significantly higher BP (standard vs. cuffless device: SBP
123.47±14.91 mmHg and 127.48±15.98 mmHg, P<0.001;
DBP 66.88±11.86 mmHg and 68.52±12.36 mmHg, P<
0.001).38) More research in pediatric populations is needed,
and a certified validation protocol for each manufacturer’s
device and algorithm should be developed. The World
Health Organization technical specification for an automated
noninvasive BP measuring device with a cuff showed concern
that BP measurements using smartphone application are in the
early stages of research and development and may lead to wrong
clinical decision due to the absence of validation protocols and
inaccuracy of measurements and expressed the expectation
that it improves hypertension diagnostics by increasing interest
and ease of BP measurement.30) It is currently in the early stage
of research, and we expect that the subject will be expanded
to children and adolescents in the future. If the problem of
low accuracy is improved, it will be possible to improve the
quality of medical care and reduce medical costs for vulnerable
populations.
Which device will replace the MS in children?
A recent study of Korean adults compared the accuracy
and errors of BP measured by 2 types of non-MS devices in an
epidemiologic survey.39) The researchers alternatively used an
MS and 2 electronic devices and calculated the BP measurement
differences, defined as BP measured by MS minus BP obtained
by 2 electronic devices. The concordance correlation coefficients
were not significantly different for SBP (mean differences: -0.52
and -0.62 mmHg, P=0.76; concordance correlation coefficients:
0.97 and 0.94), but the concordance correlation coefficient for
DBP were significantly different among manufacturers (mean
differences: -0.78 and 6.23 mmHg, P<0.01; concordance
correlation coefficients: 0.95 and 0.76).39) In 2018, a similarly
designed study of the Korean National Health and Nutrition
Examination Survey Program was conducted in children over 10
years of age to determine which BP measurement device is most
suitable for replacing MS in future surveys. A direct comparison
among the 3 devices under well-controlled BP measurement
protocols suggested significant differences among manufacturers
in children and adolescents as seen in adults, especially for DBP
(unpublished data). Two recent guidelines for hypertension in
children recommended that oscillometric devices may be used
for BP screening in children, and if they detect hypertension,
the values must be confirmed using the auscultatory method.
They emphasize that at least 3 BP measurements obtained at rest
by manual auscultation are essential when diagnosing a child
or adolescent with hypertension.2,17,40) ABPM may also help
diagnose hypertension in cases of elevated manual auscultatory
BP values.3,5)
In conclusion, although oscillometric devices have become
widely used in children, they have not yet completely replaced
MS or other auscultatory methods, especially for confirming
hypertension in children. The aneroid or hydrid auscultatory
device can be a good alternative to MS, and hybrid devices have
the advantage that they usually do not require regular calibration
of aneroid devices. There is a need for further discussion about
a BP measurement device that can replace mercury, and it can
be said that the mobile application-based BP measurement has
very high development potential because of its convenience and
accessibility, even though it is still in the early stages of research.
Footnotes
Conflicts of interest: No potential conflict of interest relevant to
this article was reported.
Acknowledgments: I acknowledge the Korean Working Group
of Pediatric Hypertension members dedicated to the research
and treatment of hypertension in children.
ORCID:
Seong Heon Kimi
iD
https://orcid.org/0000-0001-8003-3010
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79
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www.e-cep.org
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How to cite this article: Lee SH, Kim SH. Blood pressure
measurements and hypertension in infants, children, and
adolescents: from the postmercury to mobile devices. Clin
Exp Pediatr [Epub ahead of print]. https://doi.org/10.3345/
cep.2021.00143
